Life Insurance Company of North America 1601 Chestnut Street Philadelphia, Pennsylvania 19192-2235 MODIFYING PROVISIONS AMENDMENT Subscriber: Elkhart Community Schools Policy No.: OK 968926 Amendment Effective Date: June 1, 2016 This amendment is attached to and made part of the Policy specified above and the Certificates issued under it. Its provisions are intended to conform this Policy to the laws of the state in which the insured resides. The Policy and any Certificates delivered under the Group Policy are amended as follows: Arkansas residents: 1. Under the General Definitions section, the definition of Covered Accident does not include reference to an ''external'' event. Connecticut residents: 1. The following benefit is added to the Schedule of Benefits section: AMBULANCE BENEFIT Basic Benefit Equal to the lesser of billed charges or rate established by the CT Dept. of Public Health 2. In the General Definitions section the definition of Hospital and Totally Disabled are replaced with the following: Hospital An institution that meets all of the following: 1. it is licensed as a Hospital pursuant to applicable law; 2. it is primarily and continuously engaged in providing medical care and treatment to sick and injured persons; 3. it is managed under the supervision of a staff of medical doctors; 4. it provides 24-hour nursing services by or under the supervision of a graduate registered nurse (R.N.); 5. it has medical, diagnostic and treatment facilities, with major surgical facilities on its premises, or available on a prearranged basis; 6. it charges for its services. Hospital shall include a Veteran’s Administration Hospital or Federal Government Hospital and the requirement that a patient must incur an expense as an Inpatient shall be waived. The term Hospital does not include a clinic, facility, or unit of a Hospital for: 1. rehabilitation, convalescent, custodial, educational or nursing care; 2. the aged, drug addicts or alcoholics; 3. a Veteran’s Administration Hospital or Federal Government Hospital unless the Covered Person incurs an expense. 17